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Please download "Zurich HK" mobile app to enjoy a straight-through claim service for the following:

• Windscreen damage • Own car damage

l Claim result • After submitting all the required

documents, our company will contact garage to proceed with repair for the damaged vehicle

• The garage will contact you for pick up details after the damaged vehicle is repaired

• Our company will also contact you via email / mail if your claim is declined

k Claim acknowledgement

• Receive acknowledgment SMS and / or email in 2 working days

j Claim submission

• Login mobile app “Zurich HK” OR submit this claim form by email/post • Email: claims@hk.zurich.com • Post: Zurich Insurance Company Ltd, Claims

Department, 26/F, One Island East,18 Westlands Road, Island East, Hong Kong

Remarks: 1. Please report your loss(es) by submitting this Claim Form to us as soon as possible after

the date of incident. 2. For inquiry, please call our Claims Hotline at 2903 9388 or email at

claims@hk.zurich.com or fax at 2968 1660. 3. In relation to the No Claim Discount (NCD) / Claim Free Discount (CFD) operation, please

refer to Section (16) of the policy for details.

Personal Details (*Mandatory fields)

Agent / Broker (if applicable) _______________________________________ *Policy / cover note no.______________________________________________

Terms of cover □ Comprehensive cover □ Third party cover Policy expiry date (DD/MM/YY) _______________________________________

*Insured person _________________________________________________ Contact / Insured person ____________________________________________ (If the same as Insured person, please ignore this field) *Contact / Insured person mobile no. _______________________________ *Contact / Insured person email address _______________________________

Our company will send you the claim acknowledgement and direct credit claim settlement by SMS and/or email.

*Contact person / Insured person postal address _____________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Our company may contact you by email to obtain additional information to process your claim, if necessary. If you would like to change the communication channel to mail, please the box: □ By mail (If you have an insurance intermediary/agent, our company will contact you via insurance intermediary/agent.)

Motor Insurance Claim Form

The insured vehicle details

Registration no. ______________________________ Year of manufacturing ___________________________ Make and model ____________________________

What purpose was the vehicle being used at the time of the accident? □ Personal use □ Commercial use □ Hired by passenger(s) □ Other, please specify

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Section 1 Particulars of driver (*Mandatory fields) Is driver the car owner? □ No (Please fill in Parts A and B) □ Yes (Please fill in Part B only)

Part A *Name __________________________________________________________ Date of birth (DD/M/YY) __________________________________________ *HKID no. / passport ______________________________________________ *Contact no. ____________________________________________________ *Email address ____________________________________________________ Relationship with the Insured person ________________________________ *Address _____________________________________________________________________________________________________________________________ Driving license no. __________________________ ( □ Full □ Probationary) License expiry date (DD/MM/YY) ______________________________________ License issued date (DD/MM/YY) ___________________________________ Did you have the car owner’s consent to use the car prior to the accident? □ Yes □ No

Part B *Did the driver take any drugs in 12 hours prior to this accident? □ No □ Yes, please give full details ______________________________________________ *Did the driver consume any intoxicating liquor in 12 hours prior to this accident? □ No □ Yes, please give full details _______________________________ *Did the driver undergo screening breath test following this accident and what is the result? □ No □ Yes, please give full details _______________________ *Had the driver’s license ever been disqualified because of careless or dangerous driving and have points ever been deducted due to such offence(s) in the

past 3 years? □ No □ Yes, please give full details ________________________________________________________________________________________

*Has the driver been involved in previous traffic accidents over the past 3 years? □ No □ Yes, please give full details _________________________________

Claim items and documentation

Please the relevant section(s), submit the required documents together with this form to our company. Our company may request for additional documents.

Claim items Claim documents checklist

□ Damage to insured vehicle (applicable to comprehensive cover only)

1. Copy of vehicle repair quotation (the quotation should be provided to and approved by our company before

repair works are carried out)

2. Copy of photos of damaged vehicle

3. Original repair invoice(s) and receipt(s) (Applicable to windscreen damage claim)

4. Copy of vehicle registration document (both front and back pages)

5. Copy of police report and police statement (if any)

6. Copy of screening breath test report (if any)

7. Copy of driver’s driving license

8. Cope of driver’s HKID or passport

9. Letter of consent signed by the driver (Section 8 of this Form)

10. Original vehicle purchase contract / receipt / invoice (Applicable to theft loss claim)

□ • Third party property damage • Third party bodily injury

1. Copy of any claim(s) / summon(s) / correspondences from third party (if any)

2. Letter of consent signed by the driver (Section 8 of this Form)

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Section 2 Witness / passenger details

Please list the witness/passenger (if any)

Name Contact address Employee？

____________________________________________________ ________________________________________________________________________ □ Yes □ No ____________________________________________________ ________________________________________________________________________ □ Yes □ No ____________________________________________________ ________________________________________________________________________ □ Yes □ No

Section 3 Condition of damaged insured vehicle (This section is only applicable to comprehensive cover)

Will you file a damage to own insured vehicle claim? □ No (please skip this section) □ Yes (Please fill in below details and submit a repair quotation) Extent of damage □ Minor □ Moderate □ Severe Is the vehicle at the repairer’s premises? □ Yes, please provide the garage’s name, location and contact number _____________________________________

□ No, please state its current location __________________________________________________________________

Has the vehicle been retained by the government vehicle centre for inspection? □ No □ Yes, please state which centre _______________________________

Section 4 Circumstances of accident, loss or damage

Date (DD/MM/YY) ________________________________________________ Time (a.m/p.m) _____________________________________________________ Place _________________________________________________________________________________________________________________________________ Weather _________________ Speed of car _______________ Road condition □ Dry □ Wet □ Smooth □ Rough □ Uphill □ Downhill □ Flat Give full details of occurrence and make a rough sketch where appropriate showing road widths, traffic lights, signs, warnings, etc. Indicate directions of vehicle with an arrow. (You can add supplementary paper(s) if the provided space is insufficient.) Description of accident

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(Before completing the questions below, you should report the accident to the police immediately) Way of report to police □ 999 report hotline □ Police station □ Reported by other Police report no. (if any) ______________________________________

(Please attach the police statement, if any)

Have you / the driver lodged a complaint or sought compensation against other driver(s) in respect of this accident? □ Yes □ No

Have you / the driver made or received any compensation to or from the other party? □ No □ Yes, please state the amount (HKD) ____________________

Have you / the driver made any written agreement with the other party related to this accident? □ No □ Yes, please provide the original document. If not,

please state the reason(s) _______________________________________________________________________________________________________________

Sketch

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Section 5 Particulars of third party vehicle involved or of other property damaged

Was any third party vehicle damaged or property damaged? □ Involved third party vehicle damage (Please fill in Parts A and B) □ Involved third party property damage (Please fill in Part B only) □ No (please skip this section)

Part A

Name of insurance company of third party vehicle owner / driver _______________ Registration no. of third party vehicle owner / driver ________________

Type and make model of the vehicle ________________________________ Extent of damage □ Minor □ Moderate □ Severe

Name of third party vehicle owner / driver ___________________________ Contact no. of Name of third party vehicle owner / driver ___________________

Address of third party vehicle owner / driver ________________________________________________________________________________________________

Part B

Name of other damaged property ________________________________________________________________________________________________________

Name of insurance company of damaged property’s owner (Ignore this field if it is the same as above) ______________________________________________

Name of damaged property’s owner _________________________________ Extent of damage □ Minor □ Moderate □ Severe

Contact no. of damaged property’s owner (Ignore this field if it is the same as above) ____________________________________________________________

Address of damaged property’s owner (Ignore this field if it is the same as above) _______________________________________________________________

Section 6 Particulars of person(s) injured

Is / are there any person(s) injured? □ Yes (please continue to fill this section) □ No (please skip this section)

Injured person 1:

Identity of injured person □ Pedestrian □ Passenger □ Third party passenger Name _________________________________ Sex □ Male □ Female

Estimated age __________ Please indicate the injured position □ Right leg □ Left leg □ Right upper limb □ Left upper limb □ Upper body □ Head

Did the injured person remain conscious after the accident? □ Yes □ No

Extent of injuries sustained by the injured person □ Minor □ Moderate □ Severe □ Dead

How did the injured person get on the ambulance to hospital? □ N/A □ Self □ Was carried by the ambulancemen

Injured person 2: (if any)

Identity of injured person □ Pedestrian □ Passenger □ Third party passenger Name _________________________________ Sex □ Male □ Female

Estimated age __________ Please indicate the injured position □ Right leg □ Left leg □ Right upper limb □ Left upper limb □ Upper body □ Head

Did the injured person remain conscious after the accident? □ Yes □ No

Extent of injuries sustained by the injured person □ Minor □ Moderate □ Severe □ Dead

How did the injured person get on the ambulance to hospital? □ N/A □ Self □ Was carried by the ambulancemen

Injured person 3: (if any)

Identity of injured person □ Pedestrian □ Passenger □ Third party passenger Name _________________________________ Sex □ Male □ Female

Estimated age __________ Please indicate the injured position □ Right leg □ Left leg □ Right upper limb □ Left upper limb □ Upper body □ Head

Did the injured person remain conscious after the accident? □ Yes □ No

Extent of injuries sustained by the injured person □ Minor □ Moderate □ Severe □ Dead

How did the injured person get on the ambulance to hospital? □ N/A □ Self □ Was carried by the ambulancemen

(Feel free to provide other information of injured person(s) if necessary)

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Signature and chop of Insured person _________________________________________________________

Signature of driver (If the same as Insured person, please ignore this field) _____________________________________________________________

Date (DD/MM/YY) _________________________________________

Date (DD/MM/YY) ______________________________________________

Section 7 Declaration and authorization

1. I / We declare that all information and particulars contained above are true and complete to the best of my/our knowledge and belief and they are made without reservation of any kind.

2. I / We understand and agree the following issues about the arrangement of my/our personal information collected or held by Zurich Insurance Company Ltd (“the Company”). 1) The personal information of customers (include policy owners, insured persons, beneficiaries, premium payors, trustees, policy assignees

and claimants) collected or held by the Company may be used by the Company for the following obligatory purposes necessary in providing services to the customers (otherwise the Company is unable to provide services to customers who fail to provide the required information): I. to process, investigate (and assist others to investigate) and determine insurance applications, insurance claims and provide ongoing

insurance services; II. to process requests for payment, and for direct debit authorization; III. to manage any claim, action and /or proceedings brought against the customers, and to exercise the Company’s rights as more particularly

defined in applicable policy wording, including but not limited to the subrogation right; IV. to compile statistics or use for accounting and actuarial purposes; V. to meet the disclosure requirements of any local or foreign law, regulations, codes or guidelines binding on the Company and /or its group

(“Zurich Insurance Group”) and conduct matching procedures where necessary; VI. to comply with the legitimate requests or orders of the courts of Hong Kong and regulators including but not limited to the Insurance

Authority, Hong Kong Federation of Insurers, auditors, governmental bodies and government-related establishments; VII. to collect debts; VIII. to facilitate the Company’s authorized service providers to provide services to the Company and /or the customers for the above purposes;

and IX. to enable an actual or proposed assignee of the Company to evaluate the transaction intended to be the subject of the assignment.

2) The Company may provide any personal information of customers to the following parties, within or outside of Hong Kong, for the obligatory purposes:- I. companies within the Zurich Insurance Group, or any other company carrying on insurance or reinsurance related business, or an

intermediary; II. any agent, contractor or third party service provider who provides administrative, telecommunications, computer, payment or other

services to the Zurich Insurance Group in connection with the operation of its business; III. third party service providers including legal advisors, accountants, investigators, loss adjusters, reinsurers, medical and rehabilitation

consultants, surveyors, specialists, repairers, and data processors; IV. credit reference agencies, and, in the event of default, any debt collection agencies or companies carrying on claim or Investigation services; V. any person to whom the Zurich Insurance Group is under an obligation to make disclosure under the requirements of any law binding

on the Zurich Insurance Group or any of its associated companies and for the purposes of any regulations, codes or guidelines issued by governmental, regulatory or other authorities with which the Zurich Insurance Group or any of its associated companies are expected to comply;

VI. any person pursuant to any order of a court of competent jurisdiction; and VII. any actual or proposed assignee of the Zurich Insurance Group or transferee of the Zurich Insurance Group’s rights in respect of the policy

owners. 3) All customers have the right to access to, correct, or change any of their own personal information held by the Company by request in writing to

the Company’s Personal Data Privacy Officer at the address below.

Personal Data Privacy Officer 26/ F, One Island East 18 Westlands Road Island East Hong Kong

4) In accordance with the Personal Data (Privacy) Ordinance (Cap 486), the Company has the right to charge a reasonable fee for processing any

data access request. 5) In the event of any discrepancy or inconsistencies between the English and Chinese versions of this notice, the English version shall prevail.

3. I / We hereby authorize any physician, medical practitioners, hospitals or clinics by whom or where I / We have been observed or treated to give full particulars about my/our health to the Company or its agents.

4. I / We hereby further authorize any parties, including but not limited to police and government authorities, airlines, travel agents, insurance companies etc. who are in possession of my/our insurance proposal information, claim information or any related information to release part or all of the information about the subject or related incidents of injury, loss or damage to the Company or its agents.

5. A photocopy of this authorization shall be considered as effective and valid as the original.

Zurich Insurance Company Ltd (a company incorporated in Switzerland) Claims Department: 26/F, One Island East, 18 Westlands Road, Island East, Hong Kong Tel: +852 2903 9388 Fax: +852 2968 1660 Website: www.zurich.com.hk

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Private & Confidential 私人及保密文件

第八部份 Letter of Consent 同意書

Letter of Consent 同意書

To whom it may concern 敬啟者:

Ref erence no. 檔案編號: __________________________________________________________________________

Date of Incident 事故日期: ________________________________________________________________________

Vehicle Registration no. 車輛登記編號: (please fill 請填寫) ______________________________________________ ________________________________________________________________________________________________

I, , bearing HKID/passport no. hereby consent and authorize the Commissioner of Hong Kong Police and/or other relevant authority(ies) to release the statement(s) (including all relevant parties involved in the captioned accident whether or not to be replied in respect of the subsequent prosecution), personal data, sketches, MVE report, brief facts, notes of proceedings, and all other relevant information and/or document(s) in relation to the captioned traffic accident to Zurich Insurance Company Ltd and/or its representative and/or its legal representative.

The copy of this letter of Consent is as valid as the original copy.

本人, 香港身份證/護照 號碼 現同意及授權香港警務處處長及/或有關

機構就上述交通意外提供所有證人(不論控方是否檢控中依賴或否)之口供、個人資料、草圖、車輛檢驗報告、

案情撮要、法庭訴訟紀錄，及所有其他有關資料或文件，給予蘇黎世保險有限公司及/或其代表及其律師代

表。

此同意書之副本與其正本同樣有效。

Signature of the driver concerned Date (DD/MM/YY) 肇事司機簽署 日期 (日/月/年)

_______________________________________________

Name of the driver concerned 肇事司機姓名

_____________________________________________